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Serum potassium and arrhythmias.
Europace. 2009 Apr;11(4):421-2
Authors: Zaza A
Alterations in serum potassium levels are a common occurrence in clinical practice and entail a significant proarrhythmic risk. The present review is a short tutorial meant to assist clinicians in the pathophysiological interpretation of arrhythmias caused by dyskalaemia.
PMID: 19182234 [PubMed - indexed for MEDLINE]
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The management of cancer-related breakthrough pain: recommendations of a task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland.
Eur J Pain. 2009 Apr;13(4):331-8
Authors: Davies AN, Dickman A, Reid C, Stevens AM, Zeppetella G,
A task group of the Science Committee of the Association for Palliative Medicine of Great Britain and Ireland (APM) was convened to produce some up-to-date, evidence-based, practical, clinical guidelines on the management of cancer-related breakthrough pain in adults. On the basis of a review of the literature, the task group was unable to make recommendations about any individual interventions, but was able to make a series of 12 recommendations about certain generic strategies. However, most of the aforementioned recommendations are based on limited evidence (i.e., case series, expert opinion). The task group also proposed a definition of breakthrough pain, and some diagnostic criteria for breakthrough pain.
PMID: 18707904 [PubMed - indexed for MEDLINE]
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Emergency Department Bedside Ultrasonographic Measurement of the Caval Index for Noninvasive Determination of Low Central Venous Pressure.
Ann Emerg Med. 2009 Jun 24;
Authors: Nagdev AN, Merchant RC, Tirado-Gonzalez A, Sisson CA, Murphy MC
STUDY OBJECTIVE: Among adult emergency department (ED) patients undergoing central venous catheterization, we determine whether a greater than or equal to 50% decrease in inferior vena cava diameter is associated with a central venous pressure of less than 8 mm Hg. METHODS: Adult patients undergoing central venous catheterization were enrolled in a prospective, observational study. Inferior vena cava inspiratory and expiratory diameters were measured by 2-dimensional bedside ultrasonography. The caval index was calculated as the relative decrease in inferior vena cava diameter during 1 respiratory cycle. The correlation of central venous pressure and caval index was calculated. The sensitivity, specificity, and positive and negative predictive values of a caval index greater than or equal to 50% that was associated with a central venous pressure less than 8 mm Hg were estimated. RESULTS: Of 73 patients, the median age was 63 years and 60% were women. Mean time and fluid administered from ultrasonographic measurement to central venous pressure determination were 6.5 minutes and 45 mL, respectively. Of the 73 participants, 32% had a central venous pressure less than 8 mm Hg. The correlation between caval index and central venous pressure was -0.74 (95% confidence interval [CI] -0.82 to -0.63). The sensitivity of caval index greater than or equal to 50% to predict a central venous pressure less than 8 mm Hg was 91% (95% CI 71% to 99%), the specificity was 94% (95% CI 84% to 99%), the positive predictive value was 87% (95% CI 66% to 97%), and the negative predictive value was 96% (95% CI 86% to 99%). CONCLUSION: Bedside ultrasonographic measurement of caval index greater than or equal to 50% is strongly associated with a low central venous pressure. Bedside measurements of caval index could be a useful noninvasive tool to determine central venous pressure during the initial evaluation of the ED patient.
PMID: 19556029 [PubMed - as supplied by publisher]
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Comparison of the 20-Hour Intravenous and 72-Hour Oral Acetylcysteine Protocols for the Treatment of Acute Acetaminophen Poisoning.
Ann Emerg Med. 2009 Jun 24;
Authors: Yarema MC, Johnson DW, Berlin RJ, Sivilotti ML, Nettel-Aguirre A, Brant RF, Spyker DA, Bailey B, Chalut D, Lee JS, Plint AC, Purssell RA, Rutledge T, Seviour CA, Stiell IG, Thompson M, Tyberg J, Dart RC, Rumack BH
STUDY OBJECTIVE: To compare outcomes after acute acetaminophen poisoning in 2 large cohorts of patients treated with either the 20-hour intravenous or 72-hour oral acetylcysteine protocol. METHODS: We conducted a retrospective cohort study with historical control comparing patients treated with one of 2 acetylcysteine regimens. Data for the 20-hour group were obtained from a medical record review of patients on whom the 20-hour intravenous protocol was initiated in Canadian hospitals from 1980 to 2005. The 72-hour group consisted of a historical cohort of patients treated in US hospitals with the 72-hour oral protocol from 1976 to 1985. The primary outcome was hepatotoxicity (aminotransferase levels >1,000 IU/L). RESULTS: Of the 4,048 patients analyzed, 2,086 were in the 20-hour group and 1,962 were in the 72-hour group. The incidence of hepatotoxicity was 13.9% in the 20-hour group and 15.8% in the 72-hour group (-1.9% absolute difference; 95% confidence interval [CI] -4.2 to 0.3). The relative risk of hepatotoxicity was lower in the 20-hour group when acetylcysteine was initiated within 12 hours of ingestion. The relative risk was lower in the 72-hour group when acetylcysteine was initiated later than 18 hours after ingestion. There was no significant risk difference between groups when acetylcysteine treatment was started 12 to 18 hours after ingestion. One patient in the 20-hour group received a liver transplant and died because of acetaminophen toxicity compared with no liver transplants and 3 deaths in the 72-hour group. Anaphylactoid reactions to intravenous acetylcysteine were reported in 148 of 2,086 patients (7.1%; 95% CI 6.1% to 8.3%). This study is limited by comparison of 2 separate data sets from different countries and study years. CONCLUSION: The risk of hepatotoxicity differed between the 20-hour and 72-hour protocols according to the time to initiation of acetylcysteine. It favored the 20-hour protocol for patients presenting early and favored the 72-hour protocol for patients presenting late after acute acetaminophen overdose.
PMID: 19556028 [PubMed - as supplied by publisher]
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Disequilibrium Between Admitted and Discharged Hospitalized Patients Affects Emergency Department Length of Stay.
Ann Emerg Med. 2009 Jun 24;
Authors: Vermeulen MJ, Ray JG, Bell C, Cayen B, Stukel TA, Schull MJ
STUDY OBJECTIVE: Most patients are admitted to the hospital through the emergency department (ED), and ED waiting times partly reflect the availability of inpatient beds. We test whether the balance between daily hospital admissions and discharges affects next-day ED length of stay. METHODS: We conducted a cross-sectional study of hospitals in metropolitan Toronto, served by a single emergency medical services provider in a publicly funded system. During a 3-year period, we evaluated the daily ratio of admissions to discharges at each hospital and the next-day median ED length of stay in the same hospital by using linear regression. RESULTS: Across hospitals, the daily mean (SD) 50th percentile ED length of stay averaged 218 (51) minutes. As the inpatient admission-discharge ratio increased or decreased, next-day ED length of stay changed accordingly. Compared with ratios of 1.0, those less than 0.6 were associated with an 11-minute (95% confidence interval [CI] 5 to 16 minutes) shorter next-day median ED length of stay; at admission-discharge ratios of 1.3 to 1.4, ED length of stay was significantly prolonged by 5 minutes (95% CI 3 to 6 minutes). Admission-discharge ratios on weekends and among medical inpatients had a stronger influence on next-day ED length of stay; effects were also greater among higher-acuity and admitted ED patients. CONCLUSION: Disequilibrium between the number of admitted and discharged inpatients significantly affects next-day ED length of stay. Better matching of daily hospital discharges and admissions could reduce ED waiting times and may be more amenable to intervention than reducing admissions alone. The admission-discharge ratio may also provide a simple way of tracking and enhancing hospital system performance.
PMID: 19556025 [PubMed - as supplied by publisher]
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A Prediction Rule for Estimating the Risk of Bacteremia in Patients with Community-Acquired Pneumonia.
Clin Infect Dis. 2009 Jun 25;
Authors: Falguera M, Trujillano J, Caro S, Menéndez R, Carratalà J, Ruiz-González A, Vilà M, García M, Porcel JM, Torres A,
Background. We endeavored to construct a simple score based entirely on epidemiological and clinical variables that would stratify patients who require hospital admission because of community-acquired pneumonia into groups with a low or high risk of developing bacteremia. Methods. Derivation and internal validation cohorts were obtained by retrospective analysis of a database that included 3116 consecutive patients with community-acquired pneumonia from 2 university hospitals. Potential predictive factors were determined by means of a multivariate logistic regression equation applied to a cohort consisting of 60% of the patients. Points were assigned to significant parameters to generate the score. It was then internally validated with the remaining 40% of patients and was externally validated using an independent multicenter cohort of 1369 patients. Results. The overall rates of bacteremia were 12%-16% in the cohorts. The clinical probability estimate of developing bacteremia was based on 6 variables: liver disease, pleuritic pain, tachycardia, tachypnea, systolic hypotension, and absence of prior antibiotic treatment. For the score, 1 point was assigned to each predictive factor. In the derivation cohort, a cutoff score of 2 best identified the risk of bacteremia. In the validation cohorts, rates of bacteremia were <8% for patients with a score 1 (43%-49% of patients), whereas blood culture results were positive in 14%-63% of cases for patients with a score 2. Conclusions. This clinical score, based on readily available and objective variables, provides a useful tool to predict bacteremia. The score has been internally and externally validated and may be useful to guide diagnostic decisions for community-acquired pneumonia.
PMID: 19555286 [PubMed - as supplied by publisher]
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